Healthcare Provider Details

I. General information

NPI: 1689605826
Provider Name (Legal Business Name): LAUREL SURGERY & ENDOSCOPY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 04/18/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 W 12TH ST
LAUREL MS
39440-2559
US

IV. Provider business mailing address

1710 W 12TH ST
LAUREL MS
39440-2559
US

V. Phone/Fax

Practice location:
  • Phone: 601-369-2021
  • Fax:
Mailing address:
  • Phone: 601-369-2021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number025
License Number StateMS

VIII. Authorized Official

Name: LISA BERGIN
Title or Position: ADMINISTRATOR
Credential:
Phone: 601-369-2021